120
BULLER: Glaucoma After Extraction of Cataract.
lary edge of the iris. Those who operate within the capsule never get iritis. Those who make peripheric capsulotomny will notice synechiae only at the place where the capsule is opened. During the passage of the lens through the pupil, the free edge of the iris is stretched and lacerated in several places which can easily be seen. These lacerations become invisible when the iris is reduced and give rise to posterior synechiae only when the lens capsule is opened in the center. When the lens capsule is incised at the periphery only, the instillation of a one per cent. solution of eserine produces no iritis, a fact which I can demonstrate any day at the hospital.
GLAUCOMA AFTER EXTRACTION OF CATARACT. BY DR. F. BULLER. NIONTREAL, CAN.
THE precise conditions which lead to glaucoma after the successful removal of cataract are not yet so well established as to render a further study of these cases unnecessary. The three cases I propose bringing before you present some features, I think, which are worthy of consideration, and in the matter of treatment I must confess myself still in doubt as to the proper course to be pursued. It is in this direction especially that I shall be glad to hear the views of other ophthalmic surgeons who may have had a wider experience than has fallen to my lot. I shall, without further comment, proceed to give the salient features of three cases. CASE No. I.- J. M., a rugged Scotchman, aged 73. Left eye uncomplicated, mature cataract, removed early in September, I883. Ether used as an anaesthetic. The extraction was with iridectomy and peripheral capsulotomy, perfectly smooth, puncture and counter-puncture being about i mm. behind clear cornea. In healing the inner angle of wound contained just a small portion of entanged iris, not a prolapse, but just enough to show as a small dark spot beneath the conjunctiva. A slight iritis appeared at the end of the first week, but no adhesions resulted. Sixty days after extraction the eye was quiet,
HULLER: Glaucoma-after Extraction of Cataract.
121
and V. = 20/50, with + 4i sph., capsule rather dense. Discission done with two needles, moderate reaction, irregular central aperture obtained not quite as large as desired. On the I4th April following a note was made of vision with + 4i2 28 cyl. ax. go, V. = 20/30, and + 3 sp. 2 28 cyl. ax. go, reads J. i at I0" fluently. The condition of the eye appeared entirely satisfactory. For several years the eye was used freely espepecially in reading, the patient being rather a book-worm. His habits of life were regular and temperate, except that he was unduly addicted to snuff-taking. About the beginning of the year I888 he found the vision of the left eye deteriorating. Shortly afterwards I examined the eye, and discovered rather deep cupping and an atrophic appearance of the optic nerve, just as in ordinary chronic glaucoma. Tension decidedly increased, and with the usual limitation of the visual field vision was reduced to 20/70. In March, i 888, vision was reduced to 20/200. I then made a free sclerotomy downwards without benefit. In January, I 889, vision was reduced to qual. perception of light, and the eye had now a distinctly glaucomous appearance, with symptoms of considerable irritation and still greater tension. The cornea was cloudy, iris and capsule pushed forwards, and the lower lid in a condition of entropion. The right eye was now blind from complete cataract, but was otherwise healthy. On the 29th January, I889, I removed the cataract from the right, under cocaine. Recovery from the operation was perfectly normal, and the eye is as good to-cay as could be desired. The capsule is not opaque, and scarely interferes with vision. The patient, now 8i, somewhat ostentatiously declares he can see as well as ever he could in his life. The left eye has ceased to trouble him, although the lower lid still turns in, and the eye has the typical appearance of glaucoma consummatum. There is practically no anterior chamber, the iris and capsule dimly seen through the cloudy cornea are pushed forwards to its posterior surface. In addition to a general cloudiness of the cornea, there are many circumscribed, dense, interstitial, and vascularized opacities; inversion of the lid, and consequent mechanical irritation
-122
BULLER: Glaucoma after Extraction of Cataract.
of the cornea, will doubtless account, to some extent, for the unusual development of blood vessels in its substance. Another peculiarity is in the scar of the original wound, which now appears as a dense vascularized yellowish white streak across the upper margin of the cornea. That the entropion had nothing to do with the development of the glaucoma is obvious, since the lid ohly became inverted when the eye was already practically blind. As far as I could ascertain, there were three factors likely to have been instrumental in lighting up the glaucomatous process. They were: Ist, the small portion of entangled iris at the inner end of the wound; 2d, the patient's bookish propensity; 3d, the thick capsule which after discission formed a dense band above, which, to all appearances, lay along that portion of the canal of Schlemm which corresponds to the coloboma. With the band of capsule in this position and the entangled iris, in all probability excessive use of the eye in reading created sufficient irritation to obstruct the circulation of fluids in a considerable extent of Schlemm's canal, thus initiating the glaucomatous process. Should I again meet with a similar chain of circumstances, I would feel inclined to perform the sclerotomy upwards, with the hope of establishing a filtration scar through the line of obstruction. CASE NO. 2. -October 12, I887. A. D., age 73, Scotch by birth. Is a tall, robust-looking man for his age, and in good general health. Vision has been failing for some months, and there is a mature uncomplicated cataract in right eye. Left eye cataract immature: fundus seen fairly well, appears normal, except that the optic nerve is somewhat pale; V. 6/6o. Right eye extraction with iridectomy and peripheral capsulotomy done under cocaine 4%. By an error, cocaine was used three or four times several hours before the operation; only one drop was instilled five minutes prior to operation. When the cataract was removed, the cornea and eye generally was very flaccid, causing some difficulty in removing the lens completely; on account of this difficulty some lens substance was allowed to remain in the eye. Healing progressed favorably until the fourth day, when he managed to strike the covering of the eye
BULLER: Glaucoma after Extraction of Cataract.
123
with the hand and open the wound; a moderate reaction followed this injury. Seventeen days after the operation the eye was quiet, and with + I2 D., V. = 6/6o, being greatly obstructed by a thick and wrinkled capsule containing some cortical substance. Capsulotomy done with one needle. Six days later all reaction had subsided, but there was only a very small opening in the capsule, and very little improvement of vision. By the middle of December -that is, six weeks after discission - with 200 + 2.00+I-.00, V: 6/12. For about one year he continued to enjoy pretty good vision, but in May, I889, this was reduced to 6/30 by a diminution of the capsular aperture. On the 6th May, I889, capsulotomy was again performed, this time with two needles, resulting in a good-sized and nearly central aperture. This was followed by a sharp reaction for a few days. In June, I889, vision was again 6/12 with his compound glasses. A few months later he noticed a gradual diminution in the acuteness of vision, and on October 30, 6/i8 was the best he could do. At this time I could discover no positive cause for the failing vision; certainly it was not due to any fault in the capsular operation; the fundus was distinctly visible in detail, and showed no coarse changes; only a doubtful increase of tension was noticed, without cupping of the nerve or limitation of the visual field; the latter, however, was not then tested with as much care as the doubtful tension demanded. There was nothing in the appearance of the eye suggestive of glaucoma. No iris in the wound, and no adhesion of iris to the dense capsule under the edges of the pupil; the capsule was thick and white, no doubt the result of an antecedent capsulitis, together with unabsorbed cortical remnants. For fifteen months longer he continued to follow his employment (store-room inspector in a large railway company) without much difficulty, but on the 26th of January of this year -or four years and three months after the original operation -be came, on account of a recent and rather rapid failure of vision, which was now reduced to fingers at 6'. There has been no pain; "only a blur or smoke has come over the sight." The
124
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sclerotic presents a slightly glaucomatous appearance. The, cornea is faintly clouded, T + 2, and field contracted on nasal side nearly to the center. Has not seen halos. The most, in fact, the only conspicuous abnormality about the eye, is the condition of the capsule, which, in addition to the thickened appearance already mentioned, now bulges forward as a sail-like prominence in its upper part. The central aperture is clear and well-defined as ever, and the vitreous is free from opacity, so that a perfect view of the optic nerve is easily obtained. The nerve is pale, and presents a moderately deep shelving -cup; arterial pulsation is doubtful. The choroid is normal. On the same day I performed a large sclerotomy in a downward direction. No benefit came of the operation. Vision steadily diminished, and on March 3d there remained only qual. p. 1. CASE NO. 3.- March 6, I89I. The left eye now presented a mature uncomplicated cataract, which I extracted with iridectomy, using Knapp's capsule forceps instead of the cystotome for opening the capsule. The wound united kindly, and everything was entirely satisfactory until the fourth day; he then managed to strike this eye also through the bandage and reopen the wound, which remained open- three or four days, but healed perfectly at last without entangled iris or other visible complication. Three weeks after operation vision was tested, and with I80° + 3.00 + 9.00, V. = 6/20, a delicate looking shining capsule is stretched across the pupil, but without adhesion of the iris to any part of it. At the end of four weeks he was out and at work as usual, although advised that the eye, though apparently quite well, was not in a fit condition to be used. Before the end of April he was reading the evening papers at night, but outraged nature brought swift retribution. On the 2d May he came with the statement that four days previously the sight suddenly became dim and the eye very painful. Fingers at 8 feet was all he could contrive to see. There was in addition T +2, cornea steamy and pupil sluggish, capsule thicker than when last seen, somewhat pushed forwards, and beset with minute dots, which appeard ark when seen through a + 20 D. lens. Fundus seen very dimly, no details, no floating opacities
BULLER: Glaucoma after Extraction of Cataract.
125
in vitreous. He was ordered to remain quiet in a dim light, and solution of eserine i %, to be instilled three times daily. On following day V. 6/27. "The first drop took the pain away." May gth, V. 6/20, with correcting glass. June 2d. Has used the eserine once or twice daily until yesterday. Can read and write with facility, and has resumed work. Eye still a little hard, but there are no other signs of glaucoma, I80° + 1.25 + I2.00-6/I8. Advised to continue the eserine once every other day. September 20, I891. Has had no further trouble with the last eye since June. The eye looks and feels perfectly well, tension is normal, and in ordinary daylight V. field is complete. He has used one drop of the eserine solution every other day, and has worked comfortably all summer. The capsule is thin and mostly clear. It has the appearance of being stretched straight across, and not bulged. With a + 20 D. lens, it presents a series of bright folds pleated up to an irregular bright band at the upper part. The pupil is active and nowhere adherent. The optic nerve, though pale, is not cupped. The pallor of the nerve, still observable, is of no special significance, since it was present several years previously before the cataract had obscured the fundus. The right eye continues unaltered, blind but harmless, though its tension remains distinctly increased. In both patients the age, nationality, and physique were similar. In cases one and two a long interval of useful vision occurred between the operation of extraction and the glaucomatous trouble. In both a dense capsule had been divided, and the upper portion evidently rested in contact with the corresponding filtration region. This clinical observation, recorded in my note-book some years ago, has been sustained by pathological investigation, as may be gathered from Mr. Collins's valuable paper read before the Ophthalmological Society of Great Britain in I890, in which he describes that condition as an almost constant pathological state in eyes which have perished from glaucoma after extraction of cataract. In none
126
BULLER: Glaucoma after Extraction of Cataract.
of my cases were there adhesions between the capsule and
iris. In all three excessive use of the eyes seems to have been an important factor in the development of glaucoma. It is somewhat remarkable that both eyes of one patient became glaucomatous, although not the slightest tendency to glaucoma existed prior to the removal of the cataract. In the last case eserine has evidently had a curative effect, but in this instance the glaucoma was more acute, and in all probability depended on an early and injudicious use of the eye. The mechanical features here were totally different from the other two, and I am inclined to look upon the outbreak of glaucoma in this instance as an irritative condition brought on by over-exertion of the visual apparatus before the filtration region of the eye had recovered from the disturbance which a wound in the immediate vicinity, but not to any extent through the canal of Schlemm, might readily create. The operation was, so far as I can judge, a typically perfect one; nor. is there the least trace of injury or ill effect from the wound having been reopened a few days after its first closure. The capsule is, I think, certainly not in contact with the extraction scar, but then it is to be observed the eye has recovered without further operative interference, showing that the cause of the glaucoma, whatever it may have been, was of a transient nature.
BULLER: Glaucoma After Extraction of Cataract.
lary edge of the iris. Those who operate within the capsule never get iritis. Those who make peripheric capsulotomny will notice synechiae only at the place where the capsule is opened. During the passage of the lens through the pupil, the free edge of the iris is stretched and lacerated in several places which can easily be seen. These lacerations become invisible when the iris is reduced and give rise to posterior synechiae only when the lens capsule is opened in the center. When the lens capsule is incised at the periphery only, the instillation of a one per cent. solution of eserine produces no iritis, a fact which I can demonstrate any day at the hospital.
GLAUCOMA AFTER EXTRACTION OF CATARACT. BY DR. F. BULLER. NIONTREAL, CAN.
THE precise conditions which lead to glaucoma after the successful removal of cataract are not yet so well established as to render a further study of these cases unnecessary. The three cases I propose bringing before you present some features, I think, which are worthy of consideration, and in the matter of treatment I must confess myself still in doubt as to the proper course to be pursued. It is in this direction especially that I shall be glad to hear the views of other ophthalmic surgeons who may have had a wider experience than has fallen to my lot. I shall, without further comment, proceed to give the salient features of three cases. CASE No. I.- J. M., a rugged Scotchman, aged 73. Left eye uncomplicated, mature cataract, removed early in September, I883. Ether used as an anaesthetic. The extraction was with iridectomy and peripheral capsulotomy, perfectly smooth, puncture and counter-puncture being about i mm. behind clear cornea. In healing the inner angle of wound contained just a small portion of entanged iris, not a prolapse, but just enough to show as a small dark spot beneath the conjunctiva. A slight iritis appeared at the end of the first week, but no adhesions resulted. Sixty days after extraction the eye was quiet,
HULLER: Glaucoma-after Extraction of Cataract.
121
and V. = 20/50, with + 4i sph., capsule rather dense. Discission done with two needles, moderate reaction, irregular central aperture obtained not quite as large as desired. On the I4th April following a note was made of vision with + 4i2 28 cyl. ax. go, V. = 20/30, and + 3 sp. 2 28 cyl. ax. go, reads J. i at I0" fluently. The condition of the eye appeared entirely satisfactory. For several years the eye was used freely espepecially in reading, the patient being rather a book-worm. His habits of life were regular and temperate, except that he was unduly addicted to snuff-taking. About the beginning of the year I888 he found the vision of the left eye deteriorating. Shortly afterwards I examined the eye, and discovered rather deep cupping and an atrophic appearance of the optic nerve, just as in ordinary chronic glaucoma. Tension decidedly increased, and with the usual limitation of the visual field vision was reduced to 20/70. In March, i 888, vision was reduced to 20/200. I then made a free sclerotomy downwards without benefit. In January, I 889, vision was reduced to qual. perception of light, and the eye had now a distinctly glaucomous appearance, with symptoms of considerable irritation and still greater tension. The cornea was cloudy, iris and capsule pushed forwards, and the lower lid in a condition of entropion. The right eye was now blind from complete cataract, but was otherwise healthy. On the 29th January, I889, I removed the cataract from the right, under cocaine. Recovery from the operation was perfectly normal, and the eye is as good to-cay as could be desired. The capsule is not opaque, and scarely interferes with vision. The patient, now 8i, somewhat ostentatiously declares he can see as well as ever he could in his life. The left eye has ceased to trouble him, although the lower lid still turns in, and the eye has the typical appearance of glaucoma consummatum. There is practically no anterior chamber, the iris and capsule dimly seen through the cloudy cornea are pushed forwards to its posterior surface. In addition to a general cloudiness of the cornea, there are many circumscribed, dense, interstitial, and vascularized opacities; inversion of the lid, and consequent mechanical irritation
-122
BULLER: Glaucoma after Extraction of Cataract.
of the cornea, will doubtless account, to some extent, for the unusual development of blood vessels in its substance. Another peculiarity is in the scar of the original wound, which now appears as a dense vascularized yellowish white streak across the upper margin of the cornea. That the entropion had nothing to do with the development of the glaucoma is obvious, since the lid ohly became inverted when the eye was already practically blind. As far as I could ascertain, there were three factors likely to have been instrumental in lighting up the glaucomatous process. They were: Ist, the small portion of entangled iris at the inner end of the wound; 2d, the patient's bookish propensity; 3d, the thick capsule which after discission formed a dense band above, which, to all appearances, lay along that portion of the canal of Schlemm which corresponds to the coloboma. With the band of capsule in this position and the entangled iris, in all probability excessive use of the eye in reading created sufficient irritation to obstruct the circulation of fluids in a considerable extent of Schlemm's canal, thus initiating the glaucomatous process. Should I again meet with a similar chain of circumstances, I would feel inclined to perform the sclerotomy upwards, with the hope of establishing a filtration scar through the line of obstruction. CASE NO. 2. -October 12, I887. A. D., age 73, Scotch by birth. Is a tall, robust-looking man for his age, and in good general health. Vision has been failing for some months, and there is a mature uncomplicated cataract in right eye. Left eye cataract immature: fundus seen fairly well, appears normal, except that the optic nerve is somewhat pale; V. 6/6o. Right eye extraction with iridectomy and peripheral capsulotomy done under cocaine 4%. By an error, cocaine was used three or four times several hours before the operation; only one drop was instilled five minutes prior to operation. When the cataract was removed, the cornea and eye generally was very flaccid, causing some difficulty in removing the lens completely; on account of this difficulty some lens substance was allowed to remain in the eye. Healing progressed favorably until the fourth day, when he managed to strike the covering of the eye
BULLER: Glaucoma after Extraction of Cataract.
123
with the hand and open the wound; a moderate reaction followed this injury. Seventeen days after the operation the eye was quiet, and with + I2 D., V. = 6/6o, being greatly obstructed by a thick and wrinkled capsule containing some cortical substance. Capsulotomy done with one needle. Six days later all reaction had subsided, but there was only a very small opening in the capsule, and very little improvement of vision. By the middle of December -that is, six weeks after discission - with 200 + 2.00+I-.00, V: 6/12. For about one year he continued to enjoy pretty good vision, but in May, I889, this was reduced to 6/30 by a diminution of the capsular aperture. On the 6th May, I889, capsulotomy was again performed, this time with two needles, resulting in a good-sized and nearly central aperture. This was followed by a sharp reaction for a few days. In June, I889, vision was again 6/12 with his compound glasses. A few months later he noticed a gradual diminution in the acuteness of vision, and on October 30, 6/i8 was the best he could do. At this time I could discover no positive cause for the failing vision; certainly it was not due to any fault in the capsular operation; the fundus was distinctly visible in detail, and showed no coarse changes; only a doubtful increase of tension was noticed, without cupping of the nerve or limitation of the visual field; the latter, however, was not then tested with as much care as the doubtful tension demanded. There was nothing in the appearance of the eye suggestive of glaucoma. No iris in the wound, and no adhesion of iris to the dense capsule under the edges of the pupil; the capsule was thick and white, no doubt the result of an antecedent capsulitis, together with unabsorbed cortical remnants. For fifteen months longer he continued to follow his employment (store-room inspector in a large railway company) without much difficulty, but on the 26th of January of this year -or four years and three months after the original operation -be came, on account of a recent and rather rapid failure of vision, which was now reduced to fingers at 6'. There has been no pain; "only a blur or smoke has come over the sight." The
124
B3ULLER: Glaucoma After Extraction of Cataract.
sclerotic presents a slightly glaucomatous appearance. The, cornea is faintly clouded, T + 2, and field contracted on nasal side nearly to the center. Has not seen halos. The most, in fact, the only conspicuous abnormality about the eye, is the condition of the capsule, which, in addition to the thickened appearance already mentioned, now bulges forward as a sail-like prominence in its upper part. The central aperture is clear and well-defined as ever, and the vitreous is free from opacity, so that a perfect view of the optic nerve is easily obtained. The nerve is pale, and presents a moderately deep shelving -cup; arterial pulsation is doubtful. The choroid is normal. On the same day I performed a large sclerotomy in a downward direction. No benefit came of the operation. Vision steadily diminished, and on March 3d there remained only qual. p. 1. CASE NO. 3.- March 6, I89I. The left eye now presented a mature uncomplicated cataract, which I extracted with iridectomy, using Knapp's capsule forceps instead of the cystotome for opening the capsule. The wound united kindly, and everything was entirely satisfactory until the fourth day; he then managed to strike this eye also through the bandage and reopen the wound, which remained open- three or four days, but healed perfectly at last without entangled iris or other visible complication. Three weeks after operation vision was tested, and with I80° + 3.00 + 9.00, V. = 6/20, a delicate looking shining capsule is stretched across the pupil, but without adhesion of the iris to any part of it. At the end of four weeks he was out and at work as usual, although advised that the eye, though apparently quite well, was not in a fit condition to be used. Before the end of April he was reading the evening papers at night, but outraged nature brought swift retribution. On the 2d May he came with the statement that four days previously the sight suddenly became dim and the eye very painful. Fingers at 8 feet was all he could contrive to see. There was in addition T +2, cornea steamy and pupil sluggish, capsule thicker than when last seen, somewhat pushed forwards, and beset with minute dots, which appeard ark when seen through a + 20 D. lens. Fundus seen very dimly, no details, no floating opacities
BULLER: Glaucoma after Extraction of Cataract.
125
in vitreous. He was ordered to remain quiet in a dim light, and solution of eserine i %, to be instilled three times daily. On following day V. 6/27. "The first drop took the pain away." May gth, V. 6/20, with correcting glass. June 2d. Has used the eserine once or twice daily until yesterday. Can read and write with facility, and has resumed work. Eye still a little hard, but there are no other signs of glaucoma, I80° + 1.25 + I2.00-6/I8. Advised to continue the eserine once every other day. September 20, I891. Has had no further trouble with the last eye since June. The eye looks and feels perfectly well, tension is normal, and in ordinary daylight V. field is complete. He has used one drop of the eserine solution every other day, and has worked comfortably all summer. The capsule is thin and mostly clear. It has the appearance of being stretched straight across, and not bulged. With a + 20 D. lens, it presents a series of bright folds pleated up to an irregular bright band at the upper part. The pupil is active and nowhere adherent. The optic nerve, though pale, is not cupped. The pallor of the nerve, still observable, is of no special significance, since it was present several years previously before the cataract had obscured the fundus. The right eye continues unaltered, blind but harmless, though its tension remains distinctly increased. In both patients the age, nationality, and physique were similar. In cases one and two a long interval of useful vision occurred between the operation of extraction and the glaucomatous trouble. In both a dense capsule had been divided, and the upper portion evidently rested in contact with the corresponding filtration region. This clinical observation, recorded in my note-book some years ago, has been sustained by pathological investigation, as may be gathered from Mr. Collins's valuable paper read before the Ophthalmological Society of Great Britain in I890, in which he describes that condition as an almost constant pathological state in eyes which have perished from glaucoma after extraction of cataract. In none
126
BULLER: Glaucoma after Extraction of Cataract.
of my cases were there adhesions between the capsule and
iris. In all three excessive use of the eyes seems to have been an important factor in the development of glaucoma. It is somewhat remarkable that both eyes of one patient became glaucomatous, although not the slightest tendency to glaucoma existed prior to the removal of the cataract. In the last case eserine has evidently had a curative effect, but in this instance the glaucoma was more acute, and in all probability depended on an early and injudicious use of the eye. The mechanical features here were totally different from the other two, and I am inclined to look upon the outbreak of glaucoma in this instance as an irritative condition brought on by over-exertion of the visual apparatus before the filtration region of the eye had recovered from the disturbance which a wound in the immediate vicinity, but not to any extent through the canal of Schlemm, might readily create. The operation was, so far as I can judge, a typically perfect one; nor. is there the least trace of injury or ill effect from the wound having been reopened a few days after its first closure. The capsule is, I think, certainly not in contact with the extraction scar, but then it is to be observed the eye has recovered without further operative interference, showing that the cause of the glaucoma, whatever it may have been, was of a transient nature.
